SACRED HEART HEALTHCARE SYSTEM
SACRED HEART HOSPITAL
421 CHEW STREET
ALLENTOWN, PA 18102-3490
SAFETY POLICY AND PROCEDURE MANUAL
Subject: Emergency Credentialing of Volunteer
Practitioners
Approval: ___________________________
Edgardo Castro (EP Coordinator)
Approval: ___________________________
Policy Number: ICS #13
Initial Effective Date: 5/15/07
Most Recent Revision Date: 12/11; 1/13
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I.
PURPOSE:
The purpose of this policy is to provide a procedure to credential qualified volunteers to
practice in emergency situations when the immediate needs of patients cannot be met.
“Emergency” as defined in this policy is a situation resulting from natural or man-made
causes that significantly disrupts care, treatment, and service (e.g. loss of utilities due to
floods, civil disturbances, accidents or emergencies within the hospital or the community);
or that results in sudden, significantly changed, or increased demands for the hospital’s
services (e.g. bioterrorist attack, building collapse, accidents in the community with mass
casualties). These events are often “disasters” or “potential injury creating events”. Normal
credentialing methods would not allow a volunteer practitioner to provide immediate care,
treatment, or services in a disaster.
II.
POLICY:
A. The volunteers addressed in this policy include only those practitioners who are required
by law and regulation to have a license, certification, or registration to practice their
profession.
B. The option to assign disaster responsibilities to volunteer practitioners is
made on a case by case basis in accordance with the needs of the organization
and its patients, and on the qualifications of the volunteer practitioners.
C. This policy will only be implemented when:
1. The hospital’s emergency management plan has been activated.
2. Sacred Heart Healthcare System is unable to meet immediate patient care
needs.
D. Oversight of the care, treatment, and services provided by volunteer
practitioners will be by Sacred Heart Healthcare System employees. No
volunteer should function to oversee other volunteers in the provision of care,
treatment, and services, with exception of physicians. Physician oversight will be per
Medical Staff bylaws.
Emergency Credentialing of Volunteer Practitioners Policy
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Safety Manual: ICS # 13
III.
RESPONSIBILITY:
It is the responsibility of the Incident Commander or designee per Emergency
Management plan to assure compliance with this policy. The Logistics chief is
responsible to assure compliance with the Labor Pool and Credentialing functions. The
Operations Chief or his designee is responsible to assure compliance with use of volunteers
in the delivery of care, treatment, and services.
IV.
REFERENCES:
CAMH 2007
Hospital Incident Command System (HICS), Emergency Medical Services Authority, CA,
2006; (HICS Guidebook, 2006).
Sacred Heart Medical Staff Bylaws: Article 10, Section 7, part 5
V.
PROCEDURE/METHODS:
Credentialing:
A. A credentialing desk will be established within the designated Labor Pool area. NonSacred Heart volunteer practitioners who present to the Labor Pool registration desk
will be directed to the credentialing desk.
B. The following credentials will be obtained and copied for all volunteers:
1. State or Federal Photo Identification, and
2. At least one of the following
a. A current hospital picture identification card that clearly identifies
professional designation.
b. A current professional license, certification, or registration.
c. Primary source verification of licensure, certification, or registration
(if required by law and regulation to practice a profession).
d. Identification indicating that the individual is a member of a Disaster
Medical Assistance Team (DMAT), or MRC, ESAR-VAP, or other
recognized state or federal organization or group.
e. Identification that the individual has been granted authority to render
patient care, treatment, and services in disaster circumstances (such as
authority having been granted by a federal, state, or municipal entity.
f. Identification and verification in writing by current organization
member(s) who possesses personal knowledge regarding the volunteer
practitioner’s qualifications.
C. Primary source verification of licensure, certification, or registration (if required by law
and regulation to practice a profession), if not done at time of initial credentialing, must
begin as soon as the situation is under control and is completed within 72 hours from
the time the volunteer practitioner presents to the organization.
Emergency Credentialing of Volunteer Practitioners Policy
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Safety Manual: ICS # 13
D. In the extraordinary circumstance that primary source verification cannot be completed
within 72 hours, it is expected to be done as soon as possible. There must be
documentation of the following:
1. Why primary source verification could not be performed in the required
time frame
2. Evidence of a demonstrated ability to continue to provide adequate care, treatment,
and services, and
3. An attempt to rectify the situation as soon as possible.
E. Primary source verification is not required if the volunteer has not provided care,
treatment, or services under the disaster responsibilities.
F. Information will be recorded on HICS Form 253 “Volunteer Staff Registration” or
suitable substitute. Volunteers will be certified by assigned Labor Pool staff. Physician
volunteers will be certified by the VP of Medical Staff or designee.
G. Approved volunteers will be issued a Sacred Heart badge identifying their professional
credentials as well as their volunteer status.
H. Information regarding approved volunteers will be shared with Operation’s Staging
Team Leader and Planning’s Personnel Tracking Manager.
Provision of Care, Treatment, Services:
I. Assignment and delivery of volunteer to designated work area is made by Personnel
Staging Team Leader, who assures that contact is made between the volunteer and the
Sacred Heart Healthcare System employee who will provide oversight and direction.
J. Sacred Heart staff members will use the following methods to oversee and monitor the
activities of volunteers: direct observation, mentoring, and/or review of documentation.
K. Documentation of assigned work areas is recorded on HICS Form 214 “Operational
Log” or appropriate substitute. HICS Form 252 “Section Personnel Time Sheet” or
appropriate substitute is used for documenting the volunteer’s time within their
assigned area.
L. HICS Form 213 “Incident Message Form” or appropriate substitute can be used to
document communications regarding volunteers to appropriate staff.
Continuation of use of Volunteer Practitioners:
M. Within 72 hours of initiating use of volunteers, hospital command staff determine need
for continued use of disaster responsibilities assigned. All decisions are documented
per Emergency Management plan protocol.
VI.
EXCEPTIONS:
There are no exceptions to this policy.
Disclaimer Statement
This policy and the implementing procedures are intended to provide a description of recommended
courses of action to comply with statutory or regulatory requirements and/ or operational standards.
It is recognized that there may be specific circumstances not contemplated by laws or regulatory
requirements that make compliance inappropriate. For advice in these circumstances, please
consult with Risk Management/Patient Safety and/or Legal Services.
Reviewed Dates:
Revised Dates: 4/05; 12/11
Typist Name: Edgardo Castro
ICS 13 safety manual credentialing